Picture Privacy Release Form

Apollo Rehab occasionally takes photos or short videos for treatment and assessment purposes. Apollo Rehab also has a web site that is used for promotion and education. Below is permission or a decline for Apollo Rehab to use these photos/videos for educational purposes and legal promotion of the clinic.

Check Only One Box Below and Fill out Only One Section Below.

Permission to Use Photograph

I grant Apollo Rehab, its representatives and employees the right to take photographs/video. I agree that Apollo Rehab may use such photographs with or without my name and for any lawful purpose, including for example such purposes as education, publicity, illustration, advertising, and Web content.

I have read and understand the above and give permission for the above use.I DO NOT want my picture or video taken and used for Publicity but grant permission to use photos or videos for treatment or assessment purposes.I DO NOT want my picture or video for any purpose.

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The Practice

We are committed to provide the highest quality, individualized skilled therapy to promote an optimal rehabilitative recovery.